This form applies to both adults and children please complete with the information that applies to the patient named.

Do you have a Dentist?*

Yes

No

General Dentist Name

TitleFirstLastSuffix

Date of your last visit?

MM

DD

YYYY

How did you hear about Truman Ortho?

Advertisement

Internet

Family / Friend

Dentist

Name of Person Referring

TitleFirstLastSuffix

What are the main goals you would like orthodontics to accomplish for you or your child?

Have you or your child visited an orthodontist before?

Yes

No

Have we treated any other family members?

Yes

No

Family Members Name

TitleFirstLastSuffix

Have your tonsils or adenoids been removed?

Yes

No

Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?

Yes

No

Do you have any missing or extra permanent teeth?

Yes

No

Have you ever had an injury to (select all that apply)

Teeth

Mouth

Chin

Do you have speech problems?

Yes

No

Explain

Do you currently, or have you ever had, any of the following habits? (check all that apply)

Clenching/Grinding

Mouth Breathing

Thumb/Finger Sucking

Lip Sucking/Biting

Nail Biting

Chewing/Eating Problem

Is the Patient currently being treated by a physician?

Yes

No

The Reason

Do you have any allergies/sensitivities to medications or latex?

Yes

No

Please List

Are you currently taking any prescription or over-the counter medications? Please list (with dosage)

Are you pregnant or nursing?

Yes

No

-I understand the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child’s medical status.
-I herby authorize the release of any information pertaining to my child’s medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office.